Rhinoplasty

Abstract

This chapter will highlight several fundamental principles and advances in rhinoplasty. Rhinofacial analysis is very helpful in breaking down the anomaly and identifying the anatomic etiology of nasal deformity. Tip refinement is a common request but no single maneuver can be universally applied; multiple techniques and grafts must be within the surgeon’s armamentarium.

Correcting the twisted nose is challenging; both cartilage and soft tissue appear to have a degree of memory that predispose to recurrent deviations. A complete structural breakdown should be taken before the nose is realigned. This must be followed by careful and meticulous restabilization.

1 Introduction

Rhinoplasty is widely performed and is often regarded as one of the more rewarding and challenging surgeries. Many aspects of this operation give rise to the perpetual learning curve. This chapter is designed to cover broad concepts that are fundamental principles in primary rhinoplasty.

2 Surgical Anatomy of Rhinoplasty (Figs. 68.1 and 68.2)

Upper lateral cartilage: paired triangular cartilages connected medially to the middle third of the dorsal septum at a 10–15° angle. Bordered superiorly by the nasal bones, laterally by the maxillary pyriform aperture, and inferiorly by the lower lateral cartilage.

Fig. 68.1

Skeletal anatomy of nose from frontal view

Fig. 68.2

Skeletal anatomy of nose from lateral view

Lower lateral cartilage: paired C-shape cartilages with three segments (medial crus, intermediate crus, and lateral crus) that form the domes and nasal tip.

Dome: the junction between the medial and lateral crura that creates the most anterior and angulated segment of the lower lateral cartilages.

Scroll region: attachment of the upper and lower lateral cartilages.

Alae: lateral nostril walls that extend from the nasal tip to the alar crease and nasal base.

Alar crease: crease where the ala meets the cheek.

External nasal valve: the nasal aperture bordered medially by the membranous septum, superiorly and laterally by the nasal ala, and inferiorly by the nasal sill.

Internal nasal valve: the internal nasal aperture bordered medially by the caudal septum, superiorly by the upper lateral cartilage, laterally by the inferior turbinate, and inferiorly by the rim of the pyriform aperture.

Major tip support mechanisms (Fig. 68.3)

• Intrinsic strength of the lower lateral cartilages

• Attachments of medial crura of lower lateral cartilages with the caudal septum

• Attachments of the lower lateral cartilages with the upper lateral cartilages (scroll region)

Fig. 68.3

Major tip support mechanism is defined by intrinsic strength of the lower lateral cartilages and attachments of medial crura of lower lateral cartilages with the caudal septum

Fig. 68.4

Major facial landmarks

Fig. 68.5

Aesthetic nasal analysis from lateral view

Fig. 68.6

Aesthetic nasal analysis from lateral view

3 Rhinofacial Analysis

3.1 Functional Analysis

Septum: cartilaginous and/or bony deviation, dislocation, or spur.

External nasal valve: collapse. Examine from basal view during nasal inspiration.

Internal nasal valve:

• Cottle Maneuver: examiner places thumbs on patient’s cheeks and retracts the cheek soft tissue and nasal walls laterally during inspiration

• Modified Cottle Maneuver: examiner places a Freer (or other blunt instrument) into the nose to push the lateral nasal wall laterally

3.2 Aesthetic Analysis (Figs. 68.4, 68.5, and 68.6)

Upper third (Bony pyramid): fractures, deviation, symmetry, narrowing, depth of radix.

Middle third (Cartilaginous dorsum): deflection, “twisted nose,” dorsal hump.

Lower third: asymmetry, tip projection, tip rotation, alar collapse, columellar show, alar width.

Nasofrontal angle: angle formed by (1) a line drawn from the nasal tip to the nasion and (2) a line drawn from the glabella to the nasion; “ideal”: 115–130°.

Nasofacial angle: angle formed by (1) a vertical line drawn from the glabella to the pogonion and (2) a line drawn from the nasal tip to the nasion; “ideal”: 30–40°.

Nasomental angle: angle formed by (1) a line drawn from the nasion to the nasal tip and (2) a line drawn from the nasal tip to the pogonion; “ideal”: 120–130°.

Nasolabial angle: angle between the columella and the upper lip; males: 90–95°; females: 95–105°.

Columellar show: amount of columella visualized caudal to the ala on lateral view; “ideal” is 2–4 mm.

Thick skin:

• Advantages: hides imperfections in underlying nasal skeleton framework

• Disadvantages: increased scarring (increased risk of pollybeak deformity)

Thin skin:

• Advantages: allows for improved definition of underlying nasal skeleton

• Disadvantages: contour imperfections and irregularities are easily visible

4 Surgical Techniques

4.1 Incisions

• Marginal—an incision along the caudal edge of the lower lateral cartilage

• Intercartilaginous—an incision between the caudal edge of the upper lateral cartilage and the cephalic edge of the lower lateral cartilage

• Intracartilaginous (cartilage-splitting)—an incision through the lateral crus of the lower lateral cartel

• Transcolumellar—a W-shaped or inverted V-shaped incision through the columella that extends to the posterior edges of the medial crura to meet the marginal incisions

• Transfixion:

  • Full transfixion—a through-and-through incision made through the membranous septum caudal to the cartilaginous septum, separating the medial crura from the caudal septum

  • Hemitransfixion—an incision through one side of the membranous septum just caudal to the cartilaginous septum without separating the medial crus from the septum

• Alar base—an incision made through the nasal vestibule, nasal sill, and nasal crease to release the ala

4.2 Surgical Approach (Closed or Open)

4.2.1 Closed

Non-delivery: minor tip work performed through intracartilaginous incision or an intercartilaginous incision with retrograde dissection.

Delivery: extensive tip work performed after delivering the lower lateral cartilages through marginal and intercartilaginous incisions.

• Advantages—provides full access to the lower lateral cartilages to perform extensive tip work, no external scar

• Disadvantages—intercartilaginous incision disrupts a major tip support mechanism

4.2.2 Open

Performed through transcolumellar and marginal incisions

• Advantages: provides complete access to the lower lateral cartilages, septum, and upper lateral cartilages for extensive tip work, major reconstruction, revision rhinoplasty, dorsal septal deviations, easier placement of sutures/grafts/implants, and academic teaching/learning

• Disadvantages: may disrupt major tip support mechanism if medial crura are separated from the caudal septum, external scar, increased post-operative edema, more time-consuming, nasal tip anesthesia

4.3 Tip Modifications

4.3.1 Tip Narrowing/Refinement

Refinement of the broad nasal tip is one of the more common goals in cosmetic rhinoplasty. Surgical options to achieve this can be categorized as:

• Volume reduction

• Cartilage reorientation

• Augmentation

• Soft tissue debulking

Choosing the appropriate technique is highly dependent on an accurate preoperative diagnosis in terms of the anatomic etiology.

4.3.1.1 Volume Reduction

• Complete Strip: The cephalic border of the lower lateral cartilage is often the culprit in tip bulbosity and its direct excision can have dramatic effects on the nasal tip. The primary effect is to narrow the supratip region and allow the tip lobule to blend in better with the upper nose. The secondary effects of such a maneuver are to create some cephalic tip rotation as well as deprojection. This technique was referred to as the “complete strip” procedure, making reference to the complete strip of cartilage left behind.

• It is important to preserve at least 8 mm of caudal strip of alar cartilages; excessive cephalic trimming of lower lateral cartilage should not be excessive as the “dead space” created by this resection may lead to continued contracture, collapse, and tip deformities. These stigmata include excessive columellar show due to alar retraction and nasal obstruction due to collapse of the nasal side wall.

• Dome-binding suture: Single dome-binding suture: one horizontal mattress suture between the two domes used to correct a boxy or bifid tip.

• Double dome-binding suture: three sutures: one suture in each dome and one suture to bring the two domes together. Useful for more severely bifid or boxy tips, results in more narrowing than single dome-binding suture. The combination of a cephalic trim with dome-binding sutures is a useful tandem (Fig. 68.7).

• Interrupted Strip: interrupts the continuity of the lower lateral cartilage to obtain major changes in tip projection and narrowing. A bilateral, vertical dome division and resection of the intermediate crura or Goldman tip technique is useful for extremely boxy or bulbous tips with resilient intrinsic cartilage strength. Cartilaginous edges are re-approximated with simple stitches and often camouflaged with a tip graft (Fig. 68.8).

Fig. 68.7

Tip refinement using complete strip technique and double dome binding

Fig. 68.8

Tip refinement using interrupted strip technique and tip graft

4.3.1.2 Tip Augmentation

Augmentation can be an effective way of improving tip definition. The amorphous tip may be best served with a strong tip graft that protrudes beyond the existing framework and creates a new scaffold for tip support. This graft can camouflage pre-existing asymmetries, form new tip defining points, and effectively narrow the tip lobule (Fig. 68.9).

Fig. 68.9

Tip augmentation using tip graft, the outcome is better definition of the tip and more projection

Conventional “shield” tip grafts will support the tip, increase projection and create some derotation.

4.3.1.3 Soft Tissue Debulking

In individuals with extremely thick skin, who paradoxically often have a poorly developed cartilaginous framework, it may be necessary to debulk some of the overlying soft tissue envelope in order to improve the amorphous nasal tip. This is often done in conjunction with strong augmentation grafts designed to push through the thick overlying skin. This debulking must be done conservatively in order to avoid the subdermal vascular plexus and jeopardizing flap viability.

4.4 Techniques to Increase Projection

• Tripod concept: lengthen all three legs → increase projection (augment medial and lateral crura)

• Suture techniques can create small increases in projection:

• Suturing together the medial crura, septocolumellar sutures, transdomal and/or interdomal sutures

• Augmentation of tip

• Columellar strut

4.5 Techniques to Increase Rotation

• Most techniques that increase tip projection will also increase tip rotation.

• Complete strip technique with single dome-binding suture will increase rotation without major changes in projection

• Reduction of dorsal hump

4.6 Techniques to Decrease Projection

All procedures that destroy tip support mechanisms will reduce projection.

• Tripod concept: shorten all three legs → decrease projection

• Reduction of medial and lateral crura

• Complete transfixion incision

• Reduction of caudal septum

4.7 Techniques to Decrease Rotation

• The techniques to decrease tip projection typically result in a decrease in rotation

• Augmentation of nasal dorsum

• Augmentation of lateral crura with overlay grafts

4.8 Dorsal Augmentation

• Augmenting the dorsum is a very common goal.

• There are numerous techniques employed, each with their unique merits.

• The anatomic etiology of the low dorsum may be limited to the upper third, namely the nasal bones or it can be isolated to the middle vault, the classic “saddle nose deformity.”

• Augmentation can be done using preferably cartilage allograft harvested from nasal septum, conchal cartilage, or costal cartilage or by using prosthetic implants or even injectable soft tissue fillers.

4.9 Dorsal Hump Reduction

• Dorsal hump is composed of caudal anterior nasal bones and superior dorsal septal cartilage.

• Hump removal will create open roof deformity, so osteotomies are performed to medialize the nasal bones and upper lateral cartilages (Fig. 68.10).

• Hump removal may disrupt attachments of upper lateral cartilages with septum, may require spreader grafts to prevent nasal valve collapse.

• Upper lateral cartilages may collapse inferomedially away from the nasal bones causing an inverted-V deformity.

• Leaving too much dorsal septum at the anterior septal angle leaves a pollybeak deformity.

• Overresection, on the other hand, leads to more dire consequences including nasal obstruction.

• A nasion that sits low on the face will create a “pseudo-hump” and resection of this dorsum can be disastrous. Instead, one should consider augmenting the radix area and raising the nasion. This may camouflage the apparent hump and allow a more conservative resection of the dorsum.

Fig. 68.10

Hump removal will create open roof deformity, so osteotomies are performed to medialize the nasal bones and upper lateral cartilages to close the open roof deformity

4.10 Osteotomies

• Osteotomies are necessary to correct cosmetic deformities of bony upper third of nose (open roof, deviated nasal bones, narrow nasal vault, and widened nasal vault).

• Medial osteotomy: mobilizes the nasal bones to allow infracturing after the lateral osteotomies.

• Lateral osteotomy: the nasal bones along with a small portion of the maxilla are mobilized, allowing infracture of the bones.

• Intermediate osteotomy: an osteotomy performed between the medial and lateral osteotomies in conjunction with the other two. It provides additional medialization and infracturing of prominent nasal horns, severely deviated bony vaults, or excessively convex nasal bones.

4.11 Twisted Nose

• It is also important to delineate exactly which part of the nose is deviated, and in which direction.

• Deviations of the upper third are generally post-traumatic and are repaired with osteotomies. Traditional medial and lateral osteotomies do not necessarily cut through previous fractures. Because of this, it is often necessary to perform intermediate osteotomies which create smaller pieces of bone that can be better controlled and realigned.

• Middle vault deviations primarily involve the dorsal septum and straightening it can be challenging. This procedure involves release of the dorsal septum from the ULCs and progressive destabilization, realignment, followed by firm fixation and stabilization of the dorsal septum. It is usually necessary to splint the corrected cartilage with a strong piece of spreader graft.

• Significant deviations of the caudal septum may require a complete extracorporeal septoplasty and re-implantation to provide a solid dorsal and caudal “L” strut. Securing the cartilage at the dorsum to the ULCs and to the lower lateral cartilages are essential to establish a solid platform.

4.12 Functional Considerations

Alar collapse: place batten grafts caudal to the lateral crura at the point of nasal valve collapse.

Upper lateral cartilage collapse: spreader grafts placed between upper lateral cartilage and septum to widen nasal valve.

5 Complications of Rhinoplasty

Asymmetric tip: caused by unequal reduction of tip or asymmetric dome-binding sutures.

Twisted nose: caused by inadequate straightening of septum, bony vault, or asymmetric tip.

Bossing: knuckling of nasal tip caused by contractual scarring of weakened/overresected lower lateral cartilages. Patients with thin skin, bifid tips, strong cartilages, and those who have undergone vertical dome division may be at higher risk of bossing.

Treatment: excise the weakened bossing area, cover with small cartilage graft.

Saddle nose deformity: collapse of nasal dorsum caused by overresection of septum or failure to preserve a dorsocaudal L-strut.

Pollybeak deformity: soft-tissue or cartilage fullness of the supratip

• Inadequate tip support and decreased tip projection

• Excessive reduction of columella

• Inadequate reduction of dorsal hump

• Supratip dead space scar formation from inadequate skin taping

Inverted-V deformity: During dorsal hump removal, ensure preservation of the nasal mucoperichondrium, which supports the upper lateral cartilages. If nasal mucoperichondrium is violated, the upper lateral cartilages may collapse inferomedially away from the nasal bones.

If the nasal bones are inadequately infractured with osteotomies, then the patient will have an inverted-V deformity in which the caudal edges of the nasal bones are overly visible.

Treatment: new osteotomies with infracturing/narrowing of the bony nasal vault, placement of spreader grafts.

Take Home Messages

• Rhinoplasty is considered to be the most challenging, rewarding, and humbling of all otolaryngology procedures.

• No single maneuver can be applied to all rhinoplasty patients; only experience tells us how to pair an aesthetic goal with the appropriate technical maneuver.

• Every rhinoplasty operation presents the surgeon with a diversity of nasal anatomy, contours, and proportions, requiring a series of organized and interrelated surgical maneuvers tailored to each patient’s anatomical and functional needs.

• Any single suture or graft can have different outcomes, especially after long-term follow-up.

• Following sound fundamental principles, beginning with analysis, is the cornerstone to a successful rhinoplasty career.